In the week leading up to International Tuberculosis Day, which commemorates the discovery by Robert Koch of the cause of the disease in 1882, Science Speaks will look at issues, events and efforts to confront this lasting and global health threat.

Recently, Science Speaks reported on a WHO bulletin that pointed to the impact of prison incarceration on the spread of the disease, noting that prisoners’ risk of being infected with tuberculosis is 26 times higher than that of the general population, and that prisoners’ risk of developing active tuberculosis disease is 23 times higher. Today, Science Speaks opens a week of tuberculosis coverage with a second post from a February visit to Haiti (the first, posted Feb. 26, is here), looking at efforts by physician John May and the nonprofit Health through Walls to confront the disease in prisons there.

PORT AU PRINCE, HAITI – When Haiti’s Prison Civile in Port au Prince was built more than 100 years ago, it was made to hold no more than 800 men. On the day in mid-February when Sen. Patrick Leahy (D-VT), Sen. Sheldon Whitehouse (D-RI), and American Ambassador to Haiti Pamela White came to visit with staff members, it held 3,717.

The little air that circulates is thick and rank, and places to sit or lie down are scarce in such an environment. Cells built to hold a dozen inmates now hold at least 60 inmates, who, sharing suffocating quarters, sharing hammocks strung together from rags for beds, sharing razors and sharing meals of watery mush scooped from encrusted wheelbarrows, also share preventable, infectious and deadly diseases. In the last year, the prison has been home to at least 58 tuberculosis patients and 165 people living with HIV.

Court and prison officials meeting their visitors that day in February discussed the obstacles they said make the prison what it is: Justice becomes a luxury, hard to prioritize and hard to sustain in a resource-poor country beset by natural and human-wrought disasters. Political upheaval and survival crimes keep courts backed up with Sisyphean case loads, and at best the number of people being tried each week comes close to the numbers being ushered in. Compounding the effects of all of this, in a place where few could afford it anyway, Haiti’s court system doesn’t allow bail. Officials stressed, though, that things are improving, with support from a USAID grant that has brought in American court reform experts to help.

Sen. Leahy, Sen. Whitehouse, Marcelle Pomerleau Leahy listen to a presentation by prison and justice officials on efforts to alleviate overcrowding. Click on photo to enlarge; the numbers show the number of convicted prisoners : 281) and the number of those who have not been tried (“prevenus”): 3436

“If you were to come back in August, you would see a considerable reduction in numbers,” one said. Three justices were handling three cases a day, the official said, adding up to 45 cases a week. But, another added, the decisions of those cases don’t lead to automatic release of prisoners, but take time to arrive at the prison. And, he added, “as we speak now, police are out making arrests.” How many? About 45 a week.

In this way, an arrest for petty theft can lead to a death sentence, without ever being heard in court.

“The word Kafka comes to mind,” Sen. Leahy said. Leahy, chairman of the Senate Judiciary Committee as well as of the Senate Appropriations Subcommittee on State and Foreign Operations, was a prosecutor first, and he emphasized, took pride in being a tough one. The “rule of law,” is pivotal, he said to him, and to Sen. Whitehouse, also a former prosecutor and Judiciary Committee member.

Leahy last year authored and sponsored the Foreign Prison Conditions Improvement Act of 2012 (Sen. James Inhofe [R-OK] cosponsored the bill), citing, among other conditions reminiscent “of the Dark Ages,” conditions in Haiti’s Port Au Prince facility. The bill was not enacted, and Sen. Leahy is expected to resubmit it soon.

Lunch is prepared for the prisoners, outside the prison kitchen, the morning of the Senators’ and Ambassador’s visit

Leahy, whose wife, a former nurse, accompanied him on the February visit, also pushed through legislation several years ago lifting constraints on USAID that kept funding from addressing health conditions in prisons. And it is for that reason that the numbers of patients with tuberculosis and HIV was known on this day, when the visitors came. In the last year, with USAID money to support longstanding but previously largely unfunded efforts by American nonprofit Health through Walls, the group has provided X-rays for 5349 prisoners at this penitentiary. They have replicated those efforts at prisons across the country, in women’s and youth detention facilities and prisons in Hinche and Les Cayes, finding and supplying treatment for more than 200 prisoners with HIV, and more than 100 with tuberculosis.

But even before the USAID money came, the group, led by Dr. John May, and frequently with attorneys from the nonprofit Rural Justice Center, screened prisoners on their own in “blitzes,” taking and recording medical and judicial case histories with the help of volunteers in one or two days. Volunteers, from May’s work in the U.S., where he is a corrections physician, joined, testing prisoners for HIV, screening them for HIV, recording weight, blood pressure, and, for many prisoners, starting the fist medical file of their lives.

Maury Geiger, founder of Rural Justice a New Hampshire-based court reform nonprofit organization has worked with Dr. John May since 2007 to address conditions in Haitian prisons. During a 2007 visit, he listened to a young inmate, at that point sick with tuberculosis, tell the story of his arrest two years earlier on a shoplifting charge. The young man later died of multi-drug resistant tuberculosis

After medical screenings, prisoners moved on to Maury Geiger, a world weary veteran of American justice and court reform expert, who, like Leahy and Whitehouse, was once a prosecutor. Geiger, who started the Rural Justice Center in the 1980s to address inequities in access to justice in the United States, has spent years in Haiti, frequently using his own resources, to address the rights of arrestees there. In the blitzes, Geiger would ask each prisoner: why are you here? The answers: My neighbor said I stole his goat. There was a fight and I stopped to look. I got into a fight. Whether what they were accused of was true or not, some had been there for more than two years without trial. Had they been convicted of the crimes they were charged with, many would have been out by then. Instead, they were crammed into cells with others whose cycle through justice had exposed them to infectious diseases, and in turn got very sick.

In 2007, a videographer filming House call in Hell about the efforts of Health through Walls co-founder and director Dr. John May asked his motivation for continuing to return to these desperate places, against overwhelming odds of making a difference. He went over the reasons — and they are the same for his “day job” as a corrections physician in the United States — the first is that prisons, with captive populations at high risks for life threatening infectious diseases are good places to make a difference. “What you do can have a very big impact there,” he said.

He also offered the physicians’ creed: “primo no nocere” – first do no harm, and added, “Harm should not come to a prisoner as a result of being incarcerated.” In addition, he added, making prisons healthier would be good for everyone else. “You have to pay attention to prisons. That’s where the diseases are.”

The 2010 earthquake, which damaged the prison, highlighted the relevance of that last statement. Four prisoners died at the prison that day. The rest, a population of more than 4,000 that day fled, into the streets of Port au Prince and wherever else they needed to go to feel safe. The work that May had done already offered policy makers a glimpse of the illnesses those prisoners had taken with them.

“Now, thanks to John May they know much better what the needs are and how to address them, before they become catastrophes,” said Tim Rieser, the Senate Majority Clerk on Appropriations, who was among the visitors and who has worked for Leahy for years. May and Geiger’s work together is having an impact, he said. “Largely thanks to Maury Geiger, the U.S. Embassy and the Haitian government are focused on the pretrial detention problem.”

The prison still occasionally receives returned “evadees” from that day, although it is acknowledged that they are not conventional fugitives — they fled a prison that no longer had a staff or infrastructure. Efforts to round them up remain complicated, a judicial official told the visitors. “There is a major address issue,” he said. A visitor asked what an address problem was. “Whereabouts,” he clarified.

The life-threatening contagions that were bred inside the walls of the Prison Civile in Port au Prince, were at large in a city without walls.

Security dictated that the visitors in February got but an abbreviated view of what is contained within the walls of the Prison Civile’s cell blocks, but they gleaned what they could. From the prison catwalk, they watched improbable masses of prisoners emerge from narrow cell blocks into the yard for a brief daily hygiene break.

Dr. John May, co-founder and director of Health through Walls with actor Sean Penn

And after the visitors left, another visitor arrived. May had met actor Sean Penn at the Ambassador’s reception for the Senate delegation the evening before, and invited him for a tour, as well. Penn has taken a significant but quiet role (razing the ruins of the National Palace which had stayed in place for more than two years following the 2010 earthquake, was a recently noted contribution) in the country’s recovery, funding efforts for housing, health, and sanitation through his J/P Haitian Relief Organization Penn got the full tour, including the infamous, and again overcrowded Titanic Cell block, which since the earthquake has added pit toilets and urinals but, according to the day’s numbers, held nearly 2,000 of the prison’s population. Chatting with prisoners, who stood jammed against the bars for air, as much as for a glimpse of the novel visitor, Penn politely objected, finally, to staffers and volunteers who followed, taking his photo at each stop. “I don’t want this to be about me,” he explained.